Problems that Usually Need Psychotherapy or Psychiatry Treatment


Phobias are fears of specific objects or situations that are not dangerous and that most people are not afraid of. Examples would be a fear of elevators, or a fear of flying in airplanes. Usually the thing that is feared has some theoretical danger, such as that elevators could get stuck between floors or planes could crash. People don’t develop phobias of completely harmless objects like paper clips. However, phobias are usually rooted in ideas rather than experience. People who are afraid of elevators have often never been stuck in one, and people who are afraid of flying are almost never survivors of crashes.

Phobias develop when people form an unfounded idea of potential danger and then make themselves feel safe by avoiding it. An elevator-phobic person approaches an elevator and becomes anxious, which is very unpleasant. The person takes the stairs and the anxiety disappears. What the person’s brain has learned is that accepting the phobia as valid and acting on that makes you feel better. Believing in the phobia and indulging it ‘works’. Of course the person’s brain has learned something that is wrong, and the person even knows it. Unfortunately, the brain has still learned this lesson. And every time the phobia sufferer avoids the feared object, this lesson is reinforced and becomes more ingrained.

So what is the treatment? The process has to be reversed, but only very gradually so that the person can tolerate the discomfort. What a therapist would do is interview the patient in great detail and create a hierarchy of feared situations, ranked from least to most anxiety-producing. With an elevator phobia, the least might be going into an empty elevator with a friend, keeping the door open, then exiting without going up or down. The person would do this repeatedly until it no longer causes any anxiety, and then proceed to the next least anxiety-producing situation. The next might be doing the same thing without a friend. After that situation is mastered, the person might allow the elevator door to partially close before making it open again. Then allow the door to fully close before opening it, still not going up or down.  Then go up just one flight with a friend. Then go up one flight without a friend. The person practices each item on the hierarchy until it no longer causes anxiety, then moves to the next until they have completed the hierarchy, and the phobia is gone.

This is called systematic desensitization, which is an exposure treatment, and it works because every time the person is exposed to the feared situation and nothing bad happens, the person’s brain learns the new, correct lesson: elevators are not dangerous and using them makes you feel better about yourself.  The brain rewires itself through reinforcement to unlearn the phobia just as it did to learn the phobia.

I should mention here that phobia sufferers often feel as if the phobia is part of them and have difficulty believing that it can ever go away. This is yet another illustration of an important fact about feelings in general: they always feel permanent but usually are not.

Some people may want to use this information to treat a phobia by themselves, but many will want professional assistance. In seeking help, you should know that exposure treatments are a type of cognitive-behavioral therapy, and that you will need a therapist who is skilled in this type of treatment.  Another important question to ask with phobia treatment is whether a therapist offers out-of-office treatment. Some therapists, but not many, will accompany phobic patients dealing with feared situations (we do not). Other therapists will be willing to conduct telephone sessions while a phobic patient confronts a feared situation (we do this). Some kind of out-of-office treatment, in person or by phone, is often necessary to treat agoraphobia, or fear of leaving one’s home.

Some phobias are difficult to treat with systematic desensitization because they involve situations that occur infrequently, such as airplane travel or dental work. In these cases, a reasonable alternative is to ask your primary care doctor for a prescription for a few pills of a benzodiazepine tranquilizer such as Xanax. These are effective at reducing anxiety in the short term and primary care doctors are often willing to write prescriptions for small numbers of pills for patients with no history of substance abuse (long-term use can be habit-forming). Benzodiazepines are sedating so don’t use them for situations such as public speaking.

Thomas B. Hollenbach, Ph.D.

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